Role conflicts & coping strategies in caregiving. A symbolic interactionist view

Institutional health care delivery is characterized by interdependency among caregivers and between caregivers and care receivers, which leads to role conflicts. This article examines role conflicts and coping strategies of health care aides who are faced with differing expectations of RNs and residents. Guided by a symbolic interactionist perspective, ethnographic data from 12 RNs, 15 health care aides, and 32 nursing home residents of Italian-Catholic and Anglo-Saxon descent in Toronto, Ontario, Canada, was gathered. Results showed that health care aides differed in how they handled role conflict and their elderly clients' concerns. Health care aides were more likely to reject conflicting role expectations from residents than from RNs.     

Ensuring an Abuse-Free Environment:

Abuse and neglect of nursing home residents are recognized as a major concern in the United States. The small amount of research conducted to date concerning the extent and correlates of the problem of abuse highlights the need for specialized staff training in abuse prevention. The residents' right to be free from abuse demands that facility staff be equipped with an awareness of the types of abuse, how to recognize the potentially abusive situations, and how to appropriately defuse conflict. This paper describes the development and test implementation of an eight module abuse prevention curriculum designed specifically for nurse aides in long term care facilities.     

Story sharing: restoring the reciprocity of caring in long-term care

Residents in long-term care facilities often experience an interruption in the reciprocity of caring, inadvertently cut off when they enter the unfamiliar surroundings of a residential health care system. This transition from the give and take of caring to being completely cared for often leads to a breakdown of meaning, a loss of identity, and loneliness. This article addresses how an intervention called story sharing can restore the reciprocity of caring. Beginning with a review of the significance and functions of storytelling and listening, a specific story sharing intervention-the mutual sharing of everyday experiences among nurse aides and the nursing home residents for whom they care-is described. The theoretical and practice implications of story sharing are discussed.     

Job satisfaction among nurse assistants employed in nursing homes: An analysis of selected job characteristics

The quality of life of residents of nursing homes depends heavily upon the work of nurse assistants (also known as nurse aides). However, beyond basic demographic data, little is currently known about this highly important category of care providers. This study explores the relationships between selected job characteristics and job satisfaction of 138 nurse assistants employed in nursing homes in Ohio. Factor analyses reveal four dimensions among these job characteristics. These dimension are labeled supervision, personal recognition, family/ work conflict, and qualifications. Only qualifications fail to show a significant correlation with the nurse assistants' levels of job satisfaction. The strongest relationship is with supervision. The implications of the findings for job satisfaction and job performance among nurse assistants are discussed.     

“It’s a Dignity Thing”: Nursing Home Care Workers’ Use of Emotions1

This article examines how nursing home care workers use emotions to construct dignity at work. Previous scholarship has shown how the financial and organizational characteristics of nursing homes shape and constrain emotion work among staff. Using evidence gathered during 18 months of participant observation in two nursing homes and 65 interviews with staff, this article analyzes how, despite obstacles, nursing home care workers generated authentic emotional attachments to residents. Surprisingly, some staff members said they particularly appreciated working with residents difficult to control. They felt accomplished when such residents successfully transitioned from life at home to life in institutional care. Emotions created dignity for staff and induced compliance among residents. Emotions are not only generated by organizations and imposed on workers; staff themselves produced emotions—sometimes in ways consistent with organizational demands, and sometimes not—and they consistently found in their emotions a resource to manage the strains of their work lives.     

Consistent Assignment of Nurse Aides: Association With Turnover and Absenteeism

Consistent assignment refers to the same caregivers consistently caring for the same residents almost every time caregivers are on duty. This article examines the association of consistent assignment of nurse aides with turnover and absenteeism. Data came from a survey of nursing home administrators, the Online Survey Certification and Reporting data, and the Area Resource File. The measures were from 2007 and came from 3,941 nursing homes. Multivariate logistic regression models were used to examine turnover and absenteeism. An average of 68% of nursing homes reported using consistent assignment, with 28% of nursing homes using nurse aides consistent assignment at the often recommended level of 85% (or more). Nursing homes using recommended levels of consistent assignment had significantly lower rates of turnover and of absenteeism. In the multivariate analyses, consistent assignment was significantly associated with both lower turnover and lower absenteeism (p < .01). Consistent assignment is a practice recommended by many policy makers, government agencies, and industry advocates. The findings presented here provide some evidence that the use of this staffing practice can be beneficial.     

Highlights from a Study of Abuse of Patients in Nursing Homes

This article reports some major findings from a random sample survey of nurses and nurses aides in 32 long-term care facilities. After defining key terms, we review the literature in an attempt to establish what is currently known about patient maltreatment in nursing homes. Next, data from the survey are presented to profile the staff and to describe difficulties in nursing home work. Findings on the extent and correlates of physical and psychological abuse of patients are then reported. The article concludes with recommendations to reduce abuse of patients.     

Training care managers in risk assessment: Outcomes of an in-service training programme

Despite a recognition that social service workers require training in risk assessment, it would appear that there currently exists minimal information regarding appropriate models for risk assessment to underpin care managers' practice and, as a result, minimal discussion to inform considerations regarding appropriate training in this area. To date, not one study has appeared in the literature specifically examining whether in-service training provided to care managers actually results in changes to their work practices. This study provides results from an evaluation of an in-service training programme in risk assessment and demonstrates that the training had minimal impact on trainee behaviours. A number of reasons are offered as to why the training failed to transfer to practice; chief amongst these being insufficient time to learn the content of the training and factors associated with the specific work environment. Importantly, the particular model of risk assessment taught on the training programme was considered by care managers as far too time consuming and complicated to use, given the demands on their time and heavy workloads. It is suggested that if this particular risk assessment model is to be adopted by care managers, social services departments must ensure that such training is of appropriate duration to enable skills to be learnt, and that workplace contingencies are addressed to facilitate rather than hinder the use of training. These findings are considered to have practical significance for the design of similar short duration training programmes within social services.     

Commentary: The Physician's Role in Nursing Home Quality of Care: Focus on Restraints

The physician can play an important role in managing high-risk nursing home residents without restraints and working with interdisciplinary care teams in comprehensive fall evaluations. A reduction or elimination of physical restraints can be measured for a facility over time, and it represents a relevant quality indicator of physician and facility interactions during the process of care. We discuss how the physician's role fits into this quality of care equation for nursing homes and its implications for new clinical, research, and policy directions for long-term care.     

Resident-to-Resident Abuse in Nursing Homes as Reported by Nurse Aides

Information on the scale and scope of resident-to-resident abuse, including verbal, physical, material, psychological, and sexual abuse, is presented. Nursing homes (n = 249) from ten states were used, with a total of 4,451 nurse aides in these facilities returning the questionnaire. Most nursing homes experienced verbal, physical, material, and psychological abuse, but sexual abuse was less common. Our findings clearly show that both the scale and scope of resident-to-resident abuse is high in nursing homes. Resident-to-resident abuse is common enough to be considered an issue of concern impacting the quality of life and safety of many residents.     

Mental disorders among non-elderly nursing home residents

Many Medicaid beneficiaries aged 22 to 64 with serious mental illness may be admitted to nursing facilities rather than psychiatric facilities as a result of Medicaid policies prohibiting coverage of inpatient psychiatric care in institutions of mental disease while requiring states to cover nursing facility care. Using nationwide Medicaid Analytic Extract claims from 2002, we found that nearly 16% of nursing home residents aged 22 to 64 had a diagnosed mental disorder, while 45.5% received antipsychotic medication, but these rates varied widely across states. Further research is necessary to determine whether, among the nation's youngest nursing home residents, care in nursing homes is potentially substituting for care in institutions for mental disease or community-based settings.     

Mental Disorders Among Non-Elderly Nursing Home Residents

Many Medicaid beneficiaries aged 22 to 64 with serious mental illness may be admitted to nursing facilities rather than psychiatric facilities as a result of Medicaid policies prohibiting coverage of inpatient psychiatric care in institutions of mental disease while requiring states to cover nursing facility care. Using nationwide Medicaid Analytic Extract claims from 2002, we found that nearly 16% of nursing home residents aged 22 to 64 had a diagnosed mental disorder, while 45.5% received antipsychotic medication, but these rates varied widely across states. Further research is necessary to determine whether, among the nation's youngest nursing home residents, care in nursing homes is potentially substituting for care in institutions for mental disease or community-based settings.     

Conflict and Aggression as Stressors in the Work Environment of Nursing Assistants:

Elder abuse and mistreatment occuring in institutional settings is a phenomenon that is as yet poorly understood. In considering the context in which elder abuse and mistreatment may arise, understanding the caregivers' work environment is an important variable. As front line staff, nursing assistants are subject to multiple stressors that underscore the highly interpersonal nature of caregiving. This paper describes the results of a Canadian study that examined conflict, aggression, and burn-out in one group of nursing assistants. Nursing assistant burn-out scores were similar to scores reported for other health-care workers. Subjects reported that conflict with residents most commonly related to the resident wanting to go outside the facility or personal hygiene. An analysis of incident reports indicated that less than 0.3% of the physical and verbal aggression nursing assistants endure from residents is formally acknowledged. On average, a nursing assistant in this health care facility may expect to be physically assaulted by residents 9.3 times per month and verbally assaulted 11.3 times per month. Findings indicate a slight correlation between burn-out and conflict and also between burn-out and reported aggression from residents. A statistically significant relationship was noted between conflicts with residents and resident aggression from residents.     

Geropsychiatric education programs. Providing skills and understanding

1. The treatment of mental health problems is a growing concern in long-term care facilities; up to 80% of nursing home residents suffer from some type of mental illness, but most receive no active treatment. 2. Nursing home staff do not receive sufficient training on mental health issues, the aging process, and assessment and management of psychiatric symptoms in the elderly. 3. Psychiatric nurses can provide a number of quality geriatric mental health programs to increase staff knowledge and promote quality of care.     

Autonomy and Control in Everyday Life in Care of Older People in Nursing Homes

Self-control and autonomy are not guaranteed when people age and are in need of help from others, especially in institution-based housing. This occurs despite the fact that it is a generally accepted belief that care should be delivered with the greatest possible degree of independence and autonomy. This article discusses older people's experiences with and the opportunities for autonomy in institution-based housing. Through focus group interviews and observations, the daily lives of residents at two nursing homes in Sweden were studied through a comparative approach using the theoretical framework of organizational culture. Three themes emerged showing how autonomy was not a reality for the residents. The first theme revealed an ambivalent mission, indicating ambiguity as to whether the nursing home was a place to live in or a place in which to be cared for. The second theme was symbolic power, which encompassed the staff's power embedded in the organization. The third theme was the ageist approach to care, which was noted in the way staff considered the residents to be old people who were unable and unwilling to strive for autonomy. The three themes were embedded in the organizational culture and were created and recreated in the interaction between residents and staff. A key question for further research is how to change the culture to strengthen the residents’ autonomy.     

Correlates of primary orientations of volunteer ombudsmen in nursing facilities

This research investigated the significance of primary orientations to volunteer work. Based on data from 745 volunteer ombudsmen in nursing facilities ( age, 69 years), hypotheses about relationships between background, social-psychological characteristics, in-service training, and four orientations (advocate, mediator, therapeutic supporter, and undifferentiated) were studied. Most ombudsmen identified a primary orientation, and their lives as volunteers were affected by this choice. Orientations of ombudsmen had demonstrable profiles that were differentiated by the resources persons brought to the task, how their skills were developed after they became volunteers, and their eventual strategies. Advocates were distinguished from others by their relative youth, formal education, in-service training, and greater hindrances. Perhaps extending traditional conceptions of gender roles, women more often practiced skills as therapeutic supporters. Those without a primary orientation had the most negative experiences.     

Prevention of Elder Mistreatment in Nursing Homes: Competencies for Direct-Care Staff

Existing training on elder mistreatment in nursing homes focuses on detection and reporting of abuse, with little training specifically targeted toward prevention of mistreatment before it occurs. We used qualitative interviews with nursing home staff, policy makers, and related professionals to identify training needs. Based on participant accounts, we drafted a number of competencies essential for caregiver training to prevent mistreatment in nursing homes. Competencies include those dealing with definitions and policies, risks for mistreatment, communication and respect in relationships with residents, and development of a cooperative work environment. Competencies are discussed along with illustrative examples, and implications for practice and policy are addressed.     

The Influence of Agency Staffing on Quality of Care in Nursing Homes

ABSTRACT

Data from a large sample of nursing homes were used to examine the cross-sectional association between use of agency staff, regular staff, and quality. Agency use data came from a survey conducted in 2003 (N?=?1071 nursing homes). The agency and regular staff measures were for nurse aides, licensed practical nurses, and registered nurses. We used a single quality factor constructed from the 14 quality measures in Nursing Home Compare. More agency nurse aides resulted in a smaller increase in quality, compared to the use of an equivalent number of regular nurse aides. Agency registered nurse staff were associated with better quality factor scores, especially in the presence of high levels of regular licensed practical nurses. Our results have policy and practice implications, the most significant of which is that agency registered nurses may be beneficial in a wide variety of circumstances, whereas agency nurse aides and licensed practical nurses should be used with caution.